Anna Eirinberg

Dental Hygiene II
May 1, 2018
Treatment Planning

I. Assessment (Preliminary Phase)

A. Patient Interview
Patient (male, 72 years old) is here for his regular recall appointment. He has no concerns

regarding his teeth and has continued to prioritize his oral health care. Patient graduated

from dental school, although never practiced, so he understands the importance of caring

for his teeth.

B. Medical/Dental History
Medical History – Patient experiences high cholesterol and benign hypertension, but is

otherwise in excellent health. He reported herniating a disc in his spine about seven years

ago, and has since been undergoing physical therapy treatment for the pain in his back.

His daily medications include Atorvastatin (Lipitor), Atenolol, and Hydrochlorothiazide.

Dental concerns for Atorvastatin are negligible but Atenolol and Hydrochlorothiazide tend

to cause orthostatic hypotension. For this reason, having the patient sit up for a few

minutes following treatment is advised. In addition, Atenolol may slow the metabolism of

lidocaine. Although this will not affect the current treatment, it is something to keep in

mind. Patient has an allergy to Penicillin.

Dental History – Patient’s last dental prophylaxis was in September 2017. His last set of

bite wing x-rays were taken at his last cleaning appointment. Patient has no history of

sensitivity, dry mouth, or bleeding gums. He does, however, clench and grind his teeth at

night. He brushes 2-3 times per day with an Oral B electric toothbrush and flosses with un-

waxed floss at least twice per day. Patient has two dental implants on #18 and #19 and

root canal treatment on #14 and #15.

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C. Social History

For the past 15 years, patient reports smoking about 1 cigar per week, but enjoys chewing

on them 4 times per week. He used to smoke them more regularly, about 3-4 per day, but

has cut back significantly and enjoys chewing them instead. He also reports drinking about

20 alcoholic beverages per week.

D. Vital Signs

Blood pressure: 131/79. Patient is 5’7’’ and weighs 155 lbs.

E. Intra-oral/Extra-oral Examination

Intra-oral examination revealed an upper right cheek bite and a red circular lesion on the

lingual frenulum. There are two dark linear lesions on the upper left area of the hard

palate, each about 3mm in length. Incisive papilla is present and patient’s tonsils have not

been removed. Bilateral exostosis is present on the maxilla and there is exostosis on the

lower right quadrant of the mandible. There are bilateral lingual tori on the mandible. A

slight coating on the tongue was apparent with a fissured appearance. Abrasion is

localized to maxillary central incisors. Attrition is localized to the maxillary and

mandibular anterior teeth, and there is generalized yellow-brown extrinsic staining of the

teeth – probably due to smoking/chewing on cigars. Patient has generalized recession.

The color of the gingiva is generalized pink. Interdental papilla is generalized flat but

localized pointed appearance along the mandibular anteriors. Gingiva is firm and resilient

and there is a generalized stippled appearance. Localized spongy consistency near lingual

maxillary anteriors. Plaque score: 10%. All other assessments reported within normal

limits.

F. Periodontal Examination

Full mouth probing revealed generalized 4-6mm probing depths. Patient exhibited no

bleeding on probing. There was Class I furcation involvement on #17, #30, and #32 and

Class II furcation involvement on #2, #3, #14, #15, #16, and #31.

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 G. Radiographs

Radiographs showed horizontal bone loss, but did not show any subgingival calculus.

II. DH Diagnosis (Problem Identification)

A. Level of Health

Patient is in good physical health as evidenced by his lack of serious medical problems and

healthy body weight. His benign hypertension and high cholesterol levels are well-

controlled with daily medication. The patient’s social habits are less than satisfactory, but

his smoking and drinking behaviors do not seem to significantly affect his overall health.

Patient’s oral health status is good considering his age. His gingiva is healthy, his oral

hygiene care is outstanding, patient had minimal calculus, but the patient’s periodontal

status is something to be monitored.

B. Diagnosis

Patient’s periodontal case type is moderate chronic periodontitis as evidenced by Class I

and Class II furcation involvement, generalized 4-6mm probing depths, and horizontal

bone loss.

III. Plan

A. Consultations Necessary

The dentist will examine the liner lesions on the back of his hard palate. A consult from

oral pathology may be warranted if the dentist is concerned about the nature of the

lesions. Otherwise, no consultations are necessary.

B. Treatment Goals

Phase I therapy: Reduce amount of plaque and remove calculus. Patient’s overall treatment

goal is to maintain and/or arrest patient’s periodontal status. Introduce fluoride rinse to

patient’s oral hygiene regime, as well as a water flosser to clean patient’s implants and

around furcation areas.

Phase II surgical and Phase III restorative: not applicable to the patient at this time.
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IV. Implementation

Appointment 1: Establish rapport, review medical/dental history, and hand scale two

quadrants. Discuss the Bass Method of brushing because some of the patient’s recession may

be due to brushing too hard. Suggest he try a gentle toothbrush head for his Oral B because of

his receding gums and recommend a water flosser for implant care and areas with furcation

involvement.

Appointment 2: Update medical/dental history. Hand scale remaining two quadrants. Polish

with fine prophy paste. Patient is a low caries risk, so fluoride application is not necessary.

Suggest he consider smoking cessation because it is a risk factor for periodontal disease.

V. Evaluation (Phase IV maintenance)

A. Evaluation of Care

Can evaluate progress at 6-month recall appointment by assessing patient’s plaque score,

amount of calculus, and patient’s periodontal health status.

B. Follow-up Charting

Perform comprehensive periodontal exam by probing to re-assess periodontal status.

C. Radiographs

Inquire if 4 horizontal bite wing radiographs are needed.

D. Patient Oral Hygiene Behavior Changes

Follow up with patient about proper brushing technique. Inquire if he purchased a

sensitive brush head and/or water flosser and discuss his thoughts on the two.

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 References

Wilkins, E. M. (2015). Clinical practice of the dental hygienist. Philadelphia, PA: Lippincott Williams &

Wilkins.

Jeske, A. H. (2018). Mosby's dental drug reference. St. Louis, Missouri: Elsevier Health Sciences.